Diagnostic hysteroscopy and saline infusion sonography: prediction of intrauterine polyps and myomas

Endometrial polyps: diagnosis and treatment options - a review of literature

INTRODUCTION AND AIM

Endometrial polyps (EPs) are a common gynecologic condition, associated with abnormal uterine bleeding (AUB), infertility, and premalignant and malignant conditions. Technologies for diagnosis and treatment of EPs are constantly evolving. We aim to provide an updated review on diagnosis and management options for patients with EPs.

MATERIAL AND METHODS

We conducted an electronic search in databases including MEDLINE, PubMed, Cochrane Central Register and others. We included 68 publications regarding EPs, their clinical burden, diagnostic modalities, treatment options and new technologies.

RESULTS

Transvaginal ultrasound (TVS) is the common modality for EP detection and color doppler increases its diagnostic accuracy. Dilation and curettage (D&C) should be avoided for diagnosis and treatment of EPs. Hysteroscopy shows high diagnostic value in EPs and allows for both histological diagnosis and effective treatment. Office hysteroscopy and see and treat hysteroscopy without anesthesia is feasible and safe for EP diagnosis and treatment, gaining more trained surgeons globally. Effective and safe technological tools for EP resection include Laser, resectoscopes, morcellators, MyoSure, Truclear and scissors\graspers.

CONCLUSIONS

EPs are safely and effectively diagnosed and treated with the hysteroscopic tools reviewed in this article. More research is needed to define the best treatment modality.

An overview of the results of hysterosonography prior to in vitro fertilization

Objective

This study aimed to analyze the results of hysterosonography performed prior to in vitro fertilization (IVF) and to correlate anomalous findings with hysteroscopy.

Methods

Findings from 197 hysterosonograms of patients examined in an assisted reproduction clinic between January 2012 and August 2014 were included. Enrollment criteria: patients in preparation for IVF not recently submitted to uterine examination through hysterosalpingography or hysteroscopy referred to hysterosonography. Uterine cavity evaluation was considered anomalous when one or more of the following were found: polyps, submucous myomas, uterine synechiae, Müllerian duct anomalies. Individuals with cavity abnormalities that might interfere with IVF results were referred to hysteroscopy.

Results

Normal test results were seen in 170/197 of the cases (86.3%). Eighteen of the 197 cases (9.1%) were suspected for polyps, two (1%) for submucous myoma, six (3.5%) for synechiae, and one (0.5%) for Müllerian duct anomalies. Sixteen of the patients diagnosed with abnormalities underwent hysteroscopy to confirm or treat the suspected pathology. In only two cases there was no agreement between tests: one patient suspected for synechiae and another for polyps were not confirmed; another individual suspected for polyps was found to have focal endometrial thickening in hysteroscopy. The positive predictive value (PPV) in our study was 93.7%.

Conclusion

In most cases, the diagnoses obtained by hysterosonography showed normal uterine cavities. The most common anomalous findings were polyps, followed by synechiae, submucous myoma, and Müllerian duct anomalies. Hysterosonography is a good option for evaluating the uterus and offers a high positive predictive value, while hysteroscopy stands as the gold standard.

Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis

OBJECTIVE

To analyze the diagnostic accuracy of two- (2D) and three- (3D) dimensional saline contrast sonohysterography (SCSH) in the detection of endometrial polyps and submucosal uterine leiomyomas in women of reproductive age with abnormal uterine bleeding compared with gold standard hysteroscopy.

METHODS

A systematic review of diagnostic studies that compared 2D- and/or 3D-SCSH with hysteroscopy and anatomopathology was conducted according to PRISMA and SEDATE recommendations. The databases MEDLINE, EMBASE and The Cochrane Library were searched electronically using specific terms with no restriction on language or publication year. Quality assessment of included studies was performed using the QUADAS-2 tool. Meta-analysis was performed with the Meta-DiSk program and data presented as forest plots and summary receiver-operating characteristics (SROC) curves. Pooled sensitivity, specificity and positive (LR+) and negative (LR-) likelihood ratios of SCSH in the detection of uterine cavity abnormalities were calculated.

RESULTS

A total of 1398 citations were identified and five studies were included in the systematic review and meta-analysis. Pooled sensitivity and specificity of 2D-SCSH in detecting endometrial polyps were 93% (95% CI, 89-96%) and 81% (95% CI, 76-86%), respectively, with pooled LR+ of 5.41 (95% CI, 2.60-11.28) and LR- of 0.10 (95% CI, 0.06-0.17). In the detection of submucosal uterine leiomyomas, pooled sensitivity and specificity were 94% (95% CI, 89-97%) and 81% (95% CI, 76-86%), respectively, with pooled LR+ of 4.25 (95% CI, 2.20-8.21) and LR- of 0.11 (95% CI, 0.05-0.22). 2D-SCSH had good accuracy in detecting endometrial polyps and submucosal uterine leiomyomas, with areas under the SROC curves of 0.97 ± 0.02 and 0.97 ± 0.03, respectively. Studies that analyzed the diagnostic accuracy of 3D-SCSH could not be compared due to high heterogeneity related to menopausal status, type of technique used and primary outcome being investigation of infertility.

CONCLUSIONS

2D-SCSH proved to be a highly sensitive method for detection of endometrial polyps and submucosal uterine leiomyomas, making it a potential first-line diagnostic method in the work-up for women with abnormal uterine bleeding. More studies are needed on 3D-SCSH in women of reproductive age. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

A randomised controlled trial of Outpatient versus inpatient Polyp Treatment (OPT) for abnormal uterine bleeding

BACKGROUND

Uterine polyps cause abnormal bleeding in women and conventional practice is to remove them in hospital under general anaesthetic. Advances in technology make it possible to perform polypectomy in an outpatient setting, yet evidence of effectiveness is limited.

OBJECTIVES

To test the hypothesis that in women with abnormal uterine bleeding (AUB) associated with benign uterine polyp(s), outpatient polyp treatment achieved as good, or no more than 25% worse, alleviation of bleeding symptoms at 6 months compared with standard inpatient treatment. The hypothesis that response to uterine polyp treatment differed according to the pattern of AUB, menopausal status and longer-term follow-up was tested. The cost-effectiveness and acceptability of outpatient polypectomy was examined.

DESIGN

A multicentre, non-inferiority, randomised controlled trial, incorporating a cost-effectiveness analysis and supplemented by a parallel patient preference study. Patient acceptability was evaluated by interview in a qualitative study.

SETTING

Outpatient hysteroscopy clinics and inpatient gynaecology departments within UK NHS hospitals.

PARTICIPANTS

Women with AUB - defined as heavy menstrual bleeding (formerly known as menorrhagia) (HMB), intermenstrual bleeding or postmenopausal bleeding - and hysteroscopically diagnosed uterine polyps.

INTERVENTIONS

We randomly assigned 507 women, using a minimisation algorithm, to outpatient polypectomy compared with conventional inpatient polypectomy as a day case in hospital under general anaesthesia.

MAIN OUTCOME MEASURES

The primary outcome was successful treatment at 6 months, determined by the woman's assessment of her bleeding. Secondary outcomes included quality of life, procedure feasibility, acceptability and cost per quality-adjusted life-year (QALY) gained.

RESULTS

At 6 months, 73% (166/228) of women who underwent outpatient polypectomy were successfully treated compared with 80% (168/211) following inpatient polypectomy [relative risk (RR) 0.91, 95% confidence interval (CI) 0.82 to 1.02]. The lower end of the CIs showed that outpatient polypectomy was at most 18% worse, in relative terms, than inpatient treatment, within the 25% margin of non-inferiority set at the outset of the study. By 1 and 2 years the corresponding proportions were similar producing RRs close to unity. There was no evidence that the treatment effect differed according to any of the predefined subgroups when treatments by variable interaction parameters were examined. Failure to completely remove polyps was higher (19% vs. 7%; RR 2.5, 95% CI 1.5 to 4.1) with outpatient polypectomy. Procedure acceptability was reduced with outpatient compared with inpatient polyp treatment (83% vs. 92%; RR 0.90, 95% CI 0.84 to 0.97). There were no significant differences in quality of life. The incremental cost-effectiveness ratios at 6 and 12 months for inpatient treatment were £1,099,167 and £668,800 per additional QALY, respectively.

CONCLUSIONS

When treating women with AUB associated with uterine polyps, outpatient polypectomy was non-inferior to inpatient polypectomy at 6 and 12 months, and relatively cost-effective. However, patients need to be aware that failure to remove a polyp is more likely with outpatient polypectomy and procedure acceptability lower.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 65868569.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 61. See the NIHR Journals Library website for further project information.

Antibiotic Prophylaxis for Gynecologic Procedures prior to and during the Utilization of Assisted Reproductive Technologies: A Systematic Review

The use of assisted reproductive technologies (ART) has increased steadily. There has been a corresponding increase in the number of ART-related procedures such as hysterosalpingography (HSG), saline infusion sonography (SIS), hysteroscopy, laparoscopy, oocyte retrieval, and embryo transfer (ET). While performing these procedures, the abdomen, upper vagina, and endocervix are breached, leading to the possibility of seeding pelvic structures with microorganisms. Antibiotic prophylaxis is therefore important to prevent or treat any procedure-related infections. After careful review of the published literature, it is evident that routine antibiotic prophylaxis is generally not recommended for the majority of ART-related procedures. For transcervical procedures such as HSG, SIS, hysteroscopy, ET, and chromotubation, patients at risk for pelvic infections should be screened and treated prior to the procedure. Patients with a history of pelvic inflammatory disease (PID) or dilated fallopian tubes are at high risk for postprocedural infections and should be given antibiotic prophylaxis during procedures such as HSG, SIS, or chromotubation. Antibiotic prophylaxis is recommended prior to oocyte retrieval in patients with a history of endometriosis, PID, ruptured appendicitis, or multiple prior pelvic surgeries.

Surgical Management of Endometrial Polyps in Infertile Women: A Comprehensive Review

Endometrial polyps are benign localized lesions of the endometrium, which are commonly seen in women of reproductive age. Observational studies have suggested a detrimental effect of endometrial polyps on fertility. The natural course of endometrial polyps remains unclear. Expectant management of small and asymptomatic polyps is reasonable in many cases. However, surgical resection of endometrial polyps is recommended in infertile patients prior to treatment in order to increase natural conception or assisted reproductive pregnancy rates. There is mixed evidence regarding the resection of newly diagnosed endometrial polyps during ovarian stimulation to improve the outcomes of fresh in vitro fertilization cycles. Hysteroscopy polypectomy remains the gold standard for surgical treatment. Evidence regarding the cost and efficacy of different methods for hysteroscopic resection of endometrial polyps in the office and outpatient surgical settings has begun to emerge.

The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis

There is a concern regarding the risk of occult leiomyosarcomas found at surgery for presumed benign fibroids. We sought to produce a comprehensive review of published data addressing this issue and provide high-quality prevalence estimates for clinical practice and future research. A comprehensive literature search using the PubMed/MEDLINE database and the Cochrane Library was performed. Inclusion criteria were human studies, peer-reviewed, with original data, involving cases for surgery in which fibroid-related indications were the primary reason for surgery, and histopathology was provided. Candidate studies (4864) were found; 3844 were excluded after review of the abstract. The remaining 1020 manuscripts were reviewed in their entirety, and 133 were included in the Bayesian binomial random effect meta-analysis. The estimated rate of leiomyosarcoma was 0.51 per 1000 procedures (95 % credible interval (CrI) 0.16–0.98) or approximately 1 in 2000. Restricting the meta-analysis to the 64 prospective studies resulted in a substantially lower estimate of 0.12 leiomyosarcomas per 1000 procedures (95 % CrI <0.01–0.75) or approximately 1 leiomyosarcoma per 8300 surgeries. Results suggest that the prevalence of occult leiomyosarcomas at surgery for presumed uterine fibroids is much less frequent than previously estimated. This rate should be incorporated into both clinical practice and future research.

Value of 3-dimensional sonohysterography for detection of intrauterine lesions in women with abnormal uterine bleeding

STUDY OBJECTIVE

To compare 2-dimensional (2D) sonohysterography (SHG) and 3D-SHG with saline solution infusion vs diagnostic hysteroscopy for investigation of intrauterine lesions in perimenopausal and postmenopausal women with abnormal uterine bleeding.

DESIGN

Comparative observational cross-sectional study (Canadian Task Force classification II-1).

SETTING

University hospital.

PATIENTS

Fifty perimenopausal and 20 postmenopausal women with abnormal intrauterine bleeding with clinically or ultrasonically suspected intrauterine lesions.

INTERVENTIONS

Conventional 2D- and 3D ultrasonography and 2D- and 3D-SHG with saline solution infusion followed by diagnostic hysteroscopy, and endometrial curettage or subsequent operative treatment (e.g., hysterectomy, myomectomy, or polypectomy). Ultrasonographic and hysteroscopic findings were compared with histopathologic findings.

MEASUREMENTS AND MAIN RESULTS

For 2D-SHG, sensitivity, specificity, positive predictive value, negative predictive value, overall accuracy, likelihood ratio for a positive result, and likelihood ratio for a negative result were 79%, 72%, 89%, 54%, 76%, 2.82, and 0.29, respectively, and for 3D-SHG, were 92%, 89%, 96%, 80%, 91%, 8.36, and 0.09, respectively; and for diagnostic hysteroscopy, were 94%, 89%, 96%, 84%, 93%, 8.55, and 0.07, respectively. Thus, 3D-SHG was superior to 2D SHG (p = .02) and comparable to diagnostic hysteroscopy (p = .75) for diagnosis of intrauterine lesions.

CONCLUSION

3D-SHG can be used in the initial investigation of intrauterine lesions in perimenopausal and postmenopausal women with abnormal uterine bleeding before resorting to invasive procedures such as diagnostic hysteroscopy. Further studies of computer-reconstructed 3D-SHG virtual hysteroscopy are recommended.

Prevalence, 1-year regression rate, and clinical significance of asymptomatic endometrial polyps: cross-sectional study

STUDY OBJECTIVE

To estimate the prevalence, 1-year regression rate, and clinical significance of endometrial polyps in women aged 45 to 50 years.

DESIGN

Cross-sectional study (Canadian Task Force II-2).

SETTING

University teaching hospital.

PATIENTS

Two hundred fifty-seven of 1000 randomly selected women aged 45 to 50 years.

INTERVENTIONS

Transvaginal ultrasonography and saline infusion sonography were performed in all study participants and were repeated in women with endometrial polyps after 12 months. Polyps present at follow-up were removed by hysteroscopic polyp resection.

MEASUREMENTS AND MAIN RESULTS

Endometrial polyps were diagnosed in 31 women (12.1%). At 1 year, the polyp regression rate was 27%. Myomas occurred more often in women with endometrial polyps, and women with polyps experienced significantly heavier periodic bleeding compared with women without polyps.

CONCLUSION

Our study findings suggest that endometrial polyps are common in women aged 45 to 50 years and that women with such polyps experience heavier periodic bleeding. Although some polyps seem to regress spontaneously during 1-year follow-up, most seem to persist.

Flow differences between endometrial polyps and cancer: a prospective study using intravenous contrast-enhanced transvaginal color flow Doppler and three-dimensional power Doppler ultrasound

OBJECTIVES

To evaluate whether assessment of blood flow by transvaginal color Doppler and three-dimensional power Doppler imaging, enhanced by intravenous contrast, may be useful in the differentiation between benign endometrial polyps and endometrial cancer.

METHODS

A prospective study was performed comparing 17 women with benign endometrial polyps and 17 women with endometrial cancer. Transvaginal color Doppler and three-dimensional power Doppler angiography were performed before and after injection of intravenous contrast. The pulsatility index (PI) and the resistance index (RI) of the polyp feeding vessel or central vessel in malignant lesions, as well as the power Doppler endometrial flow indices vascularization index (VI), flow index (FI) and vascularization flow index (VFI), were calculated before and after enhancement by contrast, and compared between the two groups of women.

RESULTS

PI (mean difference +/- SD, 0.68 +/- 0.22; 95% CI, 0.23-1.13; P = 0.004) and RI (mean difference +/- SD, 0.16 +/- 0.08; 95% CI, 0.00-0.32; P = 0.045) were significantly lower in vessels of malignant tumors than in those of benign endometrial polyps after enhancement by intravenous contrast. No significant differences in PI, RI, VI, FI or VFI before enhancement by contrast, or in VI, FI or VFI after enhancement by contrast, were detected between women with endometrial polyps and those with endometrial cancer.

CONCLUSIONS

Transvaginal color Doppler examination enhanced by intravenous contrast may help to discriminate between benign endometrial polyps and cancer. Larger studies are required to confirm these findings.

Hysteroscopic resection of symptomatic and asymptomatic endometrial polyps

STUDY OBJECTIVE

To estimate the occurrence of malignancy and atypical hyperplasia in endometrial polyps in patients with and without symptoms.

DESIGN

Retrospective registration of all patients who underwent hysteroscopic resection of endometrial polyps. Age, menopausal status, presence or absence of symptoms, any use of hormonal medication, as well as histologic diagnosis, complications, and eventual repeated surgery were documented (Canadian Task Force classification II-3).

SETTING

Ullevaal University Hospital, Department of Gynecology.

PATIENTS

All patients who underwent hysteroscopic resection of an endometrial polyp in our department from January 1, 2001 through March 1, 2005.

INTERVENTIONS

Hysteroscopic resection of endometrial polyps.

MEASUREMENTS AND MAIN RESULTS

Four hundred eleven patients were included. One hundred twenty-nine patients (31.4%) had no symptoms. The prevalence of malignancy or atypical hyperplasia was 3.2% in women with symptoms and 3.9% in those without symptoms.

CONCLUSION

The prevalence of malignancy and atypical hyperplasia was found to be relatively high, indicating that symptomatic, as well as asymptomatic, endometrial polyps should be removed.